Pruitthealth - Augusta

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Mission Statement, the facility failed to protect the residents' right to be free from physical and sexual abuse by other residents for two of two residents (R) (R96 and R92) reviewed for abuse out of a total of 31 sampled residents. Actual harm occurred when R96 was physically abused by R64, resulting in R96 receiving a fractured clavicle and head laceration. Additionally, R92 was sexually abused by R93.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled Pressure Injury Prevention Program, the facility failed to monitor for changes and intervene when a pressure ulcer worsened for one of six residents (R) (R9) reviewed for pressure ulcers out of a total sample of 33. R9 was first identified with a pressure ulcer on 3/21/2025. There was no documented monitoring of the pressure ulcer from 3/21/2025 until 3/31/2025, when the pressure ulcer was noted to have worsened from excoriation to an unstageable pressure ulcer requiring debridement. This caused R9 actual harm when she was subsequently found to have a wound infection and osteomyelitis (infection in the bone).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week. The failure created the potential for a negative impact on residents' quality of care and had the potential to affect 84 of 84 residents who resided at the facility.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Infection Prevention and Control Plan, the facility failed to have an effective antibiotic stewardship program. This had the potential to result in residents receiving unnecessary antibiotics, increase the risk of multi-drug-resistant organisms (MDROs), and could adversely affect 84 of 84 residents who resided at the facility

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a safe, clean, homelike environment on two of three units (Unit 1 and Unit 2). Specifically, there was a strong urine smell on Unit 1 and 10 rooms on Unit 1 and Unit 2 (Rooms 1, 2, 4, 9, 13, 20, 21, 23, 25, and 26) with damaged drawer fronts. The deficient practice had the potential to place the residents residing in the rooms at risk of living in a non-homelike environment and had the potential to place the residents at risk of injury related to the damaged drawer fronts.

Inspectors wrote3. During an observation on 6/25/2025 at 8:30 am of R49's incontinent care, Certified Nurse Aide (CNA)1 failed to wash her hands after she discarded the dirty brief and dirty gloves prior to donning clean gloves to apply the clean brief. During an observation on 6/25/2025 at 10:40 am of R192's incontinent care, CNA7 failed to wash her hands after she discarded the dirty brief and dirty gloves prior to donning clean gloves to apply the clean brief. During an observation on 6/25/2025 at 11:03 am of R54's incontinent care, CNA2 failed to wash her hands after she discarded the dirty brief and dirty gloves prior to donning clean gloves to apply the clean brief. During an interview on 6/25/2025 at 11:15 am, when asked when she would change gloves during the incontinent care process, CNA2 stated that she would change gloves and wash her hands if the resident had a bowel movement. [...]

Inspectors wroteBased on observations, staff interviews, facility document review, and review of the facility policy titled Pest Control: Dietary Services, the facility failed to have an effective pest control program for the facility's only kitchen. This deficient practice had the potential to place the 84 residents residing in the facility at risk for adverse health effects and a diminished quality of life.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Patient Discharges and Transfers, the facility failed to provide written notification of a facility-initiated transfer to the resident/responsible party (RP) for one of two residents (R) (R72) reviewed for hospitalization out of a total sample of 31. The failure had the potential to affect the residents and/or their representative concerning the residents' appeal rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the comprehensive care plans for four of four residents (Resident) 96, R27, R35, and R9) out of a total sample of 31. The failure placed the residents at risk for unmet care needs and their inability to meet their maximum practicable level of functioning.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to investigate the underlying issue for significant weight loss and assess the resident for goals and interventions for weight loss for one of three residents (R) (R82) reviewed for nutritional status out of a total sample of 31. This deficient practice had the potential to place R82 at risk of unmet nutritional needs.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, F-689 Accidents - Water Temperatures, the facility failed to ensure comfortable hot water temperatures were maintained below 110 degrees Fahrenheit (F) for 12 of 40 rooms and for one of two shower rooms. The facility census was 92.

Inspectors wroteBased on observations, staff interviews, record review, and review of facility's policies titled Medication Administration: General Guidelines and Medication Administration: Insulin Injections, the facility failed to ensure the medication error rate was less than five percent (5%). Specifically, two of four nurses observed during medication administration omitted an antihypertensive medication, administered insulin using the wrong technique and administered supplements without a physician's order resulting in an error rate of 11.54 percent . The facility census was 92.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Nursing: Patient/Resident Rights, Accommodation of Needs, the facility failed to provide a Geri wheelchair to one of 44 Residents (R) (R39). This failure has the potential for diminished quality of life, and to affect the resident's mental and psychosocial wellbeing.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a safe/clean/comfortable/homelike environment for two rooms on Station one, one room on Station two, and two rooms on Station three. These rooms contained missing hinges from closet doors, missing wood from a closet drawer, stained countertops, a baseboard in disrepair, a stained bathtub with a missing faucet and a dirty fan. The facility census was 92 residents. 1. Observation on 1/9/2024 at 11:27 am of room [ROOM NUMBER] revealed bed 39-A closet door hinge missing and bed 39-B closet's drawer door missing wood. Observation on 1/10/2024 at 9:50 am of room [ROOM NUMBER] revealed bed 39-A closet door hinge missing and bed 39-B closet's drawer door missing wood. Observation on 1/11/2024 at 10:05 am of room [ROOM NUMBER] revealed bed 39-A closet door hinge missing and bed 39-B closet's drawer door missing wood. [...]

Inspectors wroteBased on staff interview, record review, review of the facility's policy titled, MDS Assessment Accuracy and review of the Resident Assessment Instrument (RAI) Manual 3.0 User's Manual, the facility failed to document the discharge status for three of 42 Residents (R) (, R101, R104, and R106) who discharged from the facility.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Activities Program, the facility failed to ensure an ongoing program of activities based on activity preference assessments for one of 44 Residents (R) (R39). This failure has the potential to decrease the resident's quality of life and psychosocial wellbeing related to the ability not to participate in group activity and socialize with other residents within the facility.

Inspectors wroteBased on observations, staff and resident interviews, record review and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure that one of 44 sampled Residents (R) (R73), received oxygen per physician's orders and to ensure safe administration of oxygen as evidenced by no oxygen in use signage.

Inspectors wroteBased on observation, staff interviews, record review and review of the facility's policy titled, Handwashing, the facility failed to reduce the spread of germs and decrease the spread of infection for one of 44 sampled Residents (R) (R25). Specifically, the facility failed to perform hand hygiene during treatment of a sacral wound.

Inspectors wroteBased on observations, interviews, and review of the policy titled COVID-19 Isolation and Cohorting Process and job descriptions titled LPN (Licensed Practical Nurse) Skin Integrity Coordinator, and Registered Nurse Skin Integrity Coordinator, the facility failed to ensure that infection control measures were followed for standard precautions during the provision of wound care for one resident (R) R#87; in addition, the facility failed to ensure staff followed appropriate protocol for personal protective equipment (PPE) use. The sample size was 39.

Inspectors wroteBased on record review, observations, interview, and review of the policy titled, Oxygen Administration, the facility failed to maintain the cleanliness of the oxygen concentrator filter, change nasal canula tubing, and bag nasal canula tubing and Continuous Positive Airway Pressure (CPAP) mask when not in use, for four residents (R) (R#5, R#31, R#52, and R#55) of four residents reviewed who required respiratory care.

Inspectors wroteBased on record review, interviews, and facility document review, the facility failed to ensure residents received physician monthly visits for the first 90 days of admission and/or every 60 days thereafter for six residents (R) (R#2, R#6, R#17, R#34, R#40, R#71) of seven residents reviewed for physician visits.

Inspectors wroteBased on record review, observations, interviews, and review of policy titled Patient/Resident Bills of Rights, the facility failed to ensure one resident (R) (R#23) of 39 sampled residents was provided dressing care/assistance with respect, consideration, or recognition of R#23's dignity. Specifically, facility staff failed to ensure R#23's shirt was put on properly which increased R#23's risk for alternation with his psychosocial well-being.

Inspectors wroteBased on record reviews, observations, interviews, and review of the policy titled, Position Description, the facility failed to ensure residents were provided menus in order for them to have food choices for three residents (R) (R#20, R#40, and R#81) and the facility failed to provide one resident (R) (R#87) of five reviewed a shower, whose preference was to receive a shower instead of a bed bath.

Inspectors wroteBased on interviews and review of the policy titled, Disbursements-Cash/Checks from Resident Trust Accounts, the facility failed to ensure one resident (R)(R#55) of two residents sampled for residents' funds, representative had readily and reasonable access to those funds. Specifically, the facility failed to honor R#55's representative (family) request for disbursement of funds.

Inspectors wroteBased on record review, interviews, and review of the policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Mission Statement, the facility failed to timely report an injury of unknown origin for one resident (R) (R#55) of two reviewed for abuse. Specifically, R#55 was noted with knee swelling and the report was not submitted timely.

Inspectors wroteBased on record review, interview, and review of the policy titled Investigation of Patient Abuse, the facility failed to conduct a thorough investigation for one resident (R) (R#70) of two reviewed for alleged staff to resident abuse. Specifically, the facility did not conduct all aspects of R#70's allegation of abuse by failing to interview relevant witnesses and report the alleged incident to the local law enforcement.

Inspectors wroteBased on record review, interviews, and review of the policy titled, Occurrence Reduction Program, the facility failed to ensure staff provided quality of care for one resident (R) (R#55) of one resident reviewed in accordance with the resident's care plan. Specifically, the facility failed to ensure staff transferred R#55 correctly with a Hoyer lift from her bed to her wheelchair and back.

Inspectors wroteBased on record review, interviews, and review of the policy titled, Patient/Resident [NAME] of Rights, the facility failed to ensure two residents (R) (R#3 and R#16) of eight reviewed were invited to participate in care plan meetings.

Inspectors wroteBased on interviews, record reviews, and policy review titled, Restorative Nursing Program, the facility failed to provide restorative nursing services to four residents (R) (R#3, R#16, R#53, and R#87) of four residents sampled for restorative services.

Inspectors wroteBased on record review, observations, interviews, and review of the facility policy titled, Smoke Free Policy, the facility failed to ensure that one of 39 sampled residents (R) (R#291) was free of potential accidents while residing in the facility. Specifically, R#291 was found smoking outside of the facility without supervision, Additionally, the facility was a smoke free facility. This had the potential for a risk of injury to the resident or possible other residents.

Inspectors wroteBased on record review, observations, interviews, and review of the policy titled, Documentation: Charting Activities of Daily Living, the facility failed to ensure one resident (R)(R#50) of one resident reviewed for bladder and bowel incontinence was provided incontinence care in a timely manner.

Inspectors wroteBased on record review, observations, interviews, and review of the policy titled, Hydration: Dietary Services, the facility failed to ensure two residents (R) (R#70, and R#23) of two residents reviewed for hydration were provided pitchers containing ice/water.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one of one resident (R) (R#293) reviewed for pain management received routine and as needed pain medication in a timely manner.